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We've gone ahead and prepopulated fields previously completed. Please check all fields
for accuracy.

Contact Information

Company Name*Required

Dispatch Contact*Required

Dispatch Email*Required

Email addresses must be in xxx@xxx.com format.

The email address is not valid. Please re-enter.

Re-Enter Email*Required

The email address you entered does not match.

Owner/Manager*Required

Must contain a first AND last name.

Address*Required

City*Required

State*Required

Zip*Required

Dispatch Phone*

()
-
x

Required

Toll-free Phone

()
-
x

Cell Phone

()
-

Will only be used by CentralDispatch

Local Phone*

()
-
x

Required

Fax

()
-

Contact Method*Required

Web Site
http://

Hours of Operation*Required(for example, M-F 8-5)

Time Zone*Required

How did you hear about us?

Company Name

Referral Code

Please specify

Promotion Code

Billing Information

Membership Level*

Billing info is the same as Contact info

Billing Contact Name*Required

Billing Email*Required

Email addresses must be in xxx@xxx.com format.

The email address is not valid. Please re-enter.

Re-Enter Email*Required

The email address you entered does not match.

Billing Phone*

() - x

Required

Billing Address*Required

Billing City*Required

Billing State*Required

Billing Zip*Required

Reference Information

How many vehicles do you typically ship per month?*Required

Year Established(for example: 2003)

Company Description*(up to 40 words)Required

Please limit Company Description to 200 characters(~40 words)

ICC-MC #Required

Dealer License #Required

Towing/Terminal License #Required

FMC License #Required

Dealer Information Owner (DIO) Details

The DIO is your dealership administrator, who will be responsible for granting users access along with site permissions within the Dealertrack network.

First NameRequired

Last NameRequired

TitleRequired

EmailRequired

Email addresses must be in xxx@xxx.com format.

The email address is not valid. Please re-enter.

Re-Enter EmailRequired

The email address you entered does not match.

Broker Bond Information

Surety Bond AgentRequired

Bonding Co. Phone

() - x

Required

Cargo Insurance Information

This is your commercial carrier cargo insurance coverage, not automobile insurance.
The cargo insurance policy must specifically include coverage of vehicles as cargo.
Your insurance company should be prepared to fax coverage to companies.

Cargo Insurance Co.Required

(Canal, Northland, etc.)

Cargo Ins. AgentRequired

Agent City/StateRequired

Agent Phone

() - x

Required

Insurance LimitRequired

Ins. DeductibleRequired

Equipment and Route Information

Number of TrucksRequired

Equipment Description:(up to 100 words)Required

Please limit Equipment Description to 500 characters(~100 words)

Route Description:(up to 40 words)Required

Please limit Route Description to 200 characters(~40 words)

User Information

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Edit ]

Username

Dealertrack ID

Email

Company TypeTest, Dealer

Billing Information

[
Edit ]

Membership Level

Billing Contact

Billing Email

Billing Phone

Billing Address

Billing City

Billing State

Billing Zip

Broker Bond

[
Edit ]

Bonding Agent

Bonding Co. Phone

Cargo Insurance

[
Edit ]

Insurance Co.

Agent

City/State

Agent Phone

Limit

Deductible

Post Vehicle

[
Edit ]

Pickup city

State/Zip,

Vehicle
()

Order ID

Operable

Price to Pay Carrier
$

COD/COP
$

Delivery city

State/Zip,

Trailer Type

Available to Ship

Additional Info

Contact Information

[
Edit ]

Company Name

Dispatch Contact

Owner/Manager

Address

City

State

Zip

Dispatch Phone

Toll-free Phone

Cell Phone

Local Phone

Fax

Contact Method

Web Site

Hours of Operation

Time Zone

Additional Information

[
Edit ]

Vehicles per Month

Year Established

Company Description:(up to 40 words)

ICC-MC #

Dealer License #

Towing/Terminal License #

FMC License #

Dealer Information Owner Details

[
Edit ]

DIO First Name

DIO Last Name

DIO Title

DIO Email

Equipment & Route

[
Edit ]

Number of Trucks

Equipment Description:

Route Description:

Member Agreement

By checking this box, you represent that you agree to the terms of the Premium Component Addendum and Access Agreement set forth at the following link.
https://www.dealertrack.com/Portal/legal-docs.aspx. The Premium Component Agreement and Access Agreement are password-protected documents. To access the documents,
please enter the password "dealertrackterms" when prompted. The password is case-sensitive.

Additionally, I understand that only bonded brokers, licensed interstate carriers,
dealers, auctions, salvage, and corporate relocators who have not previously used
CentralDispatch are eligible for the FREE TRIAL. Others (if accepted) may NOT be offered a
FREE TRIAL, but may pay for their first month in advance.